Giving hospitalists their space

Cleveland Clinicâ€™s division of general internal medicine decided
to try â€œgeographic roundingâ€ï¿½ after a patient
satisfaction survey revealed that many patients were unhappy that â€œmy
doctor is never around.â€ï¿½ That sentiment is starting to change now
that hospitalists spend more time actually talking with patients and less time getting
to them.

Cleveland Clinic's division of general internal medicine decided to try “geographic
rounding” after a patient satisfaction survey revealed that many patients were
unhappy that “my doctor is never around.” That sentiment is starting
to change now that hospitalists spend more time actually talking with patients and
less time getting to them.

“If a family came in and wanted to talk to us, it could be a 10- to 15-minute
walk to the room, 10 minutes to talk and another 10 to 15 minutes to walk back to
where you were. We were spending 45 minutes just to talk to one family,” said
Robert Patrick, MD, an associate staff member in the clinic's department of hospital
medicine. Before the clinic implemented geographic rounding, which assigns hospitalists
to one unit per shift, there were five hospitalist teams, each with an average of
12 patients spread over seven floors, said Dr. Patrick. Most hospitalists had fewer
than 30% of their patients on any one floor.

Physicians and nurses at the clinic love the new arrangement, he said. “Nurses
can get hold of doctors when they need them because they may be on the floor for six
hours at a time. Doctors get fewer pages and they are no longer wearing out a pair
of shoes every six months walking all over the hospital,” he explained. Also,
length-of-stay is down dramatically and patient satisfaction seems to be up.

Other benefits cited by hospitalists who have tried such geographic rounding include
being able to talk to specialists face-to-face and perform multidisciplinary rounding
with nurses, social workers, physical therapists and others. However, the system doesn't
always run smoothly, with barriers ranging from physician complaints about feeling
isolated or overworked to problems coordinating physician shifts with bed assignments.
If you can overcome those problems, however, the system can boost morale and energize
staff, said Douglas J. Apple, ACP Member, who practices at Spectrum Health's Butterworth
Hospital in Grand Rapids, Mich. “It really empowers them [nurses] to have us
there,” he said. “And that happiness carries over to us.”

Coordinating bed assignments

The toughest implementation barrier cited by all experts was bed assignment.

“Getting emergency patients to the floor in a timely manner is always a challenge
and when you enter in the variable of hospitalist assignments, it can be even harder,”
said Amy E. Boutwell, ACP Member, a hospitalist at Newton Wellesley Hospital in Cambridge,
Mass., and content director for the Institute for Healthcare Improvement. “If
you get a patient through the ED but all the beds on your ward are full, you must
have a mechanism to also admit to another floor. Do you hand them off to a colleague
or do you travel to see them? It's a question that has to be resolved.”

Various hospitals resolve it differently, though. Daniel J. Brotman, FACP, director
of the hospitalist program at Johns Hopkins Hospital in Baltimore, said the challenge
is greatest at hospitals that function at or near capacity.

“You can't run a hospital like a hotel and force patients to vacate their beds
after three days,” he said. “The ED has to send patients somewhere,
and you either have to be willing to place patients elsewhere or give the hospitalist
covering a geographic unit the ability to say ‘no’ to getting new patients.
We are fortunate to be able to cap our service when our beds are full.”

In addition to being allowed to turn down new patients, hospitalists never get boarders
on the dedicated unit at Johns Hopkins. “If you are on our unit, you are our
patient,” he said. Having a large house staff program helps such restrictions
to exist, Dr. Brotman noted, since they can absorb the extra patients.

He also stressed that proper physician-to-patient ratios must be maintained. “We
have to get past the expectation that hospitalists will keep taking overflow patients,
because it can reach unsafe levels for a single provider, particularly when geographic
dispersion is thrown into the mix,” he said. “Larger teams—such
as those with housestaff or physician extenders—are better equipped to handle
overflows and to cover a geographically dispersed group of patients. Single hospitalists
are not.”

Like Johns Hopkins, Cleveland Clinic often is filled to capacity and Dr. Patrick reiterated
the importance of not putting incoming patients just anywhere. One mechanism that
helps preserve the geographic unit is to hold six beds starting at 5:00 p.m. for patients
assigned to that unit's hospitalist. Also, specialists had to accept that not all
of their admissions would go to one floor anymore.

“The institution had to take a risk in giving us preference for the beds on
our unit and it didn't work out well at first, but by making the people in charge
of bed assignment accountable, we are finally getting more than 70% of a hospitalist's
patients on one floor and the other 30% divided between two additional floors, not
the 14 that they could possibly be on,” he said.

The rotation is shuffled every two weeks, which brings that number closer to 90% of
a hospitalist's patients on one floor. Also, all hospitalist patients are on just
four floors, so when a hospitalist has to accept patients who cannot be placed on
their unit, they are not spread all over.

“This dramatic improvement was achieved without any statistically significant
change in daily census equity amongst the five teams. The dramatic variations in team
census that we feared never actually materialized,” he said.

Dealing with isolation

Physician isolation has been the only real problem at Butterworth Hospital, a 500-bed
facility, since it started a hospitalist-based unit in July, said Dr. Apple. The program
began by assigning one hospitalist to cover about 16 to 20 beds on a specific 33-bed
unit for seven days at a time. (The seven-day model eliminates weekend handoffs, resulting
in better continuity of care, he explained.)

“Physicians also had concerns that being the only health care provider on the
unit would cause them to be interrupted more frequently than usual as ‘easier’
access to them would allow RNs, case workers and families more occasions for inappropriate
stoppage of work flow,” he said.

Dr. Apple hopes to address this issue by getting all 33 beds under the hospitalist
service and staffing it with two doctors at a time. “We would like to give
the hospitalist a partner so that when he or she is swamped and an urgent task arises,
there is someone there to help them,” he said. “They are not handling
everything on their own.”

He explained that all hospitalists within the Michigan Medical P.C. Hospitalist Division
have been involved with the scheduling process and the work flow of the unit.

“This has become a rounding pattern that is owned by the group, not just my
pilot. The physicians have taken this new change with an open mind as it was clear
to them that we needed a more efficient way to round in order to improve patient satisfaction
and build a stronger culture of relationships with nursing and case management staff,”
he said.

“Once the scheduler had everyone's recommendation, we implemented the seven-day
week that follows an admitting shift of M-F 2:00 p.m. to 10:00 p.m., with the following
Monday becoming the unit-based week. This way everyone can plan which week is their
unit-based week.”

The new system has been well-received, even by the most skeptical physicians, he said.
“Once their turn has come up, most of them enjoy it and even offer ideas on
ways to make it work even better,” Dr. Apple said.

One such idea that has been implemented: adding photocopiers and printers to the hospitalists'
“bullpen” area so they don't have to walk back and forth four times
just to discharge a patient. The idea was so popular that several other units in the
hospital have adopted it, too.

Pilot plans are under way to use geographic rounding in other areas of Butterworth
Hospital, such as the ICU step-down unit.

Failed experiment

Staten Island University Hospital in New York City had a very different experience
with geographic rounding. After implementing it three years ago, its hospitalists
scrapped the plan after about 18 months. Aaron L. Gottesman, FACP, director of hospitalist
services, calls it “an unfortunate experiment that failed miserably”
for reasons that he describes as specific to his facility.

“Keeping the work load balanced meant more than one doctor saw patients on
each floor. This lopsided distribution meant that as each week went on, hospitalists
had to be moved to other floors to keep their load even,” he said.

Also, he said the system seemed to lead to hospitalists receiving less respect. “We
got treated as everything from the intern to the attending and were expected to take
care of all problems on the unit,” he explained.

Hospitalist satisfaction was further hurt as some nurses would wait until the housestaff
was in conference and bring their problems to the hospitalist. Resident education
was disrupted as well. “The usual line of teaching was not being followed.
PGY2s forgot what their role was,” said Dr. Gottesman.

His associate director, Mona Patel, DO, added that she and her colleagues missed the
variety of patients seen on a typical day when the hospitalist is not limited to a
particular unit. She also said that Staten Island University Hospital is not as spread
out as some facilities and her colleagues tend to cherish the time spent traveling
between units as a chance to ponder and decompress.

During their short foray into the geographic model, “vigorous” arguments
about it were held monthly. “It was the single largest source of dissatisfaction
and aggravation for our staff,” Dr. Gottesman said.

His advice to others hoping for a more successful outcome? “Think this through
carefully for all stakeholders and make sure everyone's roles are well-defined.”

Beth Thomas Hertz is a freelance writer based in Copley, Ohio.

Tips to make geographic rounding work

Get support from the highest levels of the institution and full buy-in from top administrators
before proceeding.

Set limits. Don't accept an unlimited number of patients. Don't do the work that interns should
be doing. Don't let boarders take up beds in the dedicated unit.

Partner with nurses. They want this to work even more than you do, so listen to their concerns and work
together to develop guidelines that help the unit function optimally.

Commit to change. If change is a priority for everyone it is more likely to work.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.